Managing COVID-19 in an Australian designated isolation facility: Implications for current and future healthcare crises based on in-depth interviews

Health care workers’ (HCWs) lived experiences and perceptions of the pandemic can prove to be a valuable resource in the face of a seemingly persistent Novel coronavirus disease 2019 (COVID-19)–to inform ongoing efforts, as well as identify components essential to a crisis preparedness plan and the issues pertinent to supporting relevant, immediate change. We employed a phenomenological approach and, using purposive sampling, conducted 39 semi-structured interviews with senior healthcare professionals who were employed at a designated COVID-19 facility in New South Wales (NSW), Australia during the height of the pandemic in 2020. Participants comprised administrators, heads of department and senior clinicians. We obtained these HCWs’ (i) perspectives of their lived experience on what was done well and what could have been done differently and (ii) recommendations on actions for current and future crisis response. Four themes emerged: minimise the spread of disease at all times; maintain a sense of collegiality and informed decision-making; plan for future crises; and promote corporate and clinical agility. These themes encapsulated respondents’ insights that should inform our capacity to meet current needs, direct meaningful and in situ change, and prepare us for future crises. Respondents’ observations and recommendations are informative for decision-makers tasked with mobilising an efficacious approach to the next health crisis and, in the interim, would aid the governance of a more robust workforce to effect high quality patient care in a safe environment.


Study design
This qualitative study was conducted using a phenomenological approach through individual semi-structured in-depth interviews. Addressing the study questions "What could have been done, or done differently to better respond to the pandemic?" and "What would you like to see maintained as we move into 'COVID-19 normal' operations?", researchers aimed to describe staff's perspective of changes in their lived experience at the height of the pandemic in 2020 and their recommendations on actions that could facilitate their workplace's response to COVID-19 and preparedness for future health crises.

Procedure
A pilot was undertaken to test the interview script's face and content validity with the assistance of clinical staff based at the local Public Health Unit. The wording of one question early in the script was modified to better elicit the views of the participant about the impact of the pandemic on themselves and their staff.
In-depth, semi-structured individual interviews were conducted in person or via online video (Zoom), according to the participant's choice. The interviewers were three of the coauthors all of whom were female, masters or doctorate qualified staff in public health positions and had research experience. Researchers had no relationship with participants prior to the study. Participants were asked a preliminary question about their roles prior to and subsequently during the height of the pandemic, which enabled confirmation of their involvement in the hospital's pandemic response. The interviewer then loosely followed a script that supported in-depth discussion of respondents' lived experiences and perceptions on the subjects of staff stress and anxiety, changes in workplace policies and procedures, communication methods, challenges, areas for improvement and recommendations for healthcare response and preparedness. The interviewer used probing questions to gain more in-depth responses and aid clarification. In instances when a response was unclear, considered incomplete or lacked detail to be as informative as possible, the interviewer probed using questions such as "Can you tell me more about . . .", "Could you give me an example of . . ." and "What did you think of . . .". All interviews were recorded with the interviewees' consent.

Participants and setting
All participants worked at a large tertiary teaching hospital that is a designated COVID-19 management facility in NSW, Australia, which received confirmed COVID-19 patients from late January 2020. Purposive and snowball sampling methods were employed (see Table 1 for a description of the professional groups). The Director of Infectious Diseases and Prevention and the Clinical Nurse Consultant and lead of Infection Control at the hospital each nominated potential key informants the administrative team and departments central to the hospital's pandemic response, resulting in 28 employees being invited to participate. An additional 12 individuals were recommended by interviewees and subsequently participated. Each key informant was sent a letter of introduction with details of the study and the contact details of the Principal Investigator. Subsequent communication by telephone and email confirmed consent to participate in a semi-structured interview with an expected duration of approximately 45 minutes and an interview appointment.

Data analysis
Interview audio-recordings were imported into a commercial program that produced a rough transcription. The interviewer cleaned the initial transcript by assigning speakers to the script and correcting text and punctuation.
Data were analysed using Colaizzi's distinctive seven step process [28] that provides a rigorous analysis, with each step staying close to the data, which includes familiarisation, identifying significant statements, formulating meanings, clustering themes, developing an exhaustive description, producing the fundamental structure and seeking verification of the fundamental structure. Researchers engaged in ongoing analyses. Transcripts were analysed by at least two researchers using a standard template, before discussions with the wider research team about emerging themes to inform the focus of subsequent interviews.
Following the transcription of the first few interviews, a review of the completed templates by research team members confirmed persistent themes. The team was responsive and open to what was in the data and allowed it to guide an iterative approach to analysis. Researchers analysed the transcripts independently by bracketing data on preconceived ideas and strictly following Marrow's modification of Colaizzi's method described above. Early analysis allowed the initial development of a coding framework that underwent ongoing development as transcripts were re-read and reviewed. Researchers reviewed emerging findings at regular team meetings until data saturation occurred and used consensus to resolve disagreements.
A key to reading the quotes is provided below: 1. [] indicates the researcher has added the narrative to make the context and/or meaning clearer, or replaced some identifiable text with de-identifiable text.
2. . . . means that words, phrases or sentences of the interview have been deleted to make the context and/or meaning clearer.
3. () located after each original participant quote, contains that particular participant's numerical pseudonym.

Rigor/Trustworthiness
The criteria of credibility, dependability and conformability [29] were used to confirm the rigor of the findings. Following the transcription of the first few interviews, a peer review process was used by the research team members to confirm persistent themes. We adhered to all assumptions and strategies of the qualitatively driven designs. We were responsive and open to what was in the data and allowed the data to guide our iterative approach to analysis. We reviewed emerging findings during daily team meetings to ensure data saturation and consensus among study team members. This was done to ensure the credibility of research.

Ethical considerations
This study was approved by the Local Health District Ethics Committee (2020/ETH01674). All participants received information about the study, and a consent form, which they were asked to read, sign and return. They were made aware that they could refuse to answer any question and could terminate the interview at any time. Our study adhered to standard ethical processes for qualitative research to ensure the anonymity of participants and confidentiality of the data.

A description of participants and interviews
Thirty-nine interviews were conducted via Zoom (N = 35) and face-to-face (N = 4). One clinician did not respond to our request for an appointment although previously agreeing to participate; no reason was obtained. All participants were employed in roles with a primary focus on the provision of health care in the height of the pandemic. We obtained over-representation from the emergency department (ED), intensive care unit (ICU), respiratory medicine and infectious diseases (ID) departments including the COVID clinic and ward, which were deemed high exposure environments and reflected the departments' representativeness in the list of potential key informants. Twenty were in newly created roles working either on the COVID-19 ward or in another capacity (Table 1). Interviews had a duration of 30 to 104 minutes, averaging 60 minutes and were conducted from November 2020 to February 2021.

Key considerations for an effective response
The unknown characteristics of the virus, initially amplified by a plethora of information from local and international sources, were a cause of heightened anxiety and stress. HCWs were acutely affected by a number of factors, among them the potential shortage of and education about PPE use, a tremendous COVID-19 related workload, leave cancellations, and moral dilemmas around the provision of less-than-optimal care and the social isolation of patients. The initial absence of guidelines and anticipated directives from the Ministry of Health stymied the process of informed decision-making. Participants had a range of experiences of and considerations about measures undertaken or lacking to address safe health care delivery. Four themes encapsulated respondents' lived experiences and reflections on what was done well, what could have been done differently, and considerations for ongoing and future provision of health care (Fig 1): minimising the spread of disease at all times, maintaining a sense of collegiality and promoting informed decision-making, maintaining a plan for future crises and promoting corporate and clinical agility. We have provided selected quotations throughout the Results and have presented detailed quotations in Table 2.     1(c) Equipping the COVID ward with a permanent nurse unit manager and staff eliminated the daily task of training nurses from a temporary pool, and reduced time pressures on clinicians as well as the anxiety of patients whose questions previously went unanswered at best. Permanent staffing fostered teamwork and increased competency, valued in a highly stressful environment.
And so, you train someone up, and they'll be gone the next day, you train someone else up, and they'll be gone the next day . . . The patients they were helping would ask them questions, and they wouldn't know the answers. Sometimes they just make answers up. And that's when the shortcuts get made. . . (P01) 1(d) The social isolation of patients who were already experiencing limited physical contact was distressing for all involved. Staff described the moral dilemma as they struggled to abide by the 'no visitor' policy, particularly for patients who were at the end of their life. Acknowledging the unnatural caring situation, equipment and technology facilitated patient contact with family and loved ones. Staff struggled with, but appreciated, the need to limit visitor numbers. Theme 2. Maintain a sense of collegiality and promote informed decision-making. Effective management enabling a quick pace of change across the facility, most consequential during the initial uncertainties such as virus-host interaction and length of period of transmissibility, was dependent on the leadership of and collaboration among staff and fit-forpurpose communication methods, channels and communicators. The majority of participants, including the Heads of Departments, spoke passionately about frequent and productive inter-department and department-executive interactions that permitted 'on-tap' problem solving for the continuation of a range of routine services employing innovative approaches. A critical facilitator was the creation of three hierarchical committees, one of which was the Clinical Expert Advisory Group (CEAG), which met as frequently as the situation required, daily or more often, and continues to meet more than a year and a half on from its inception.
2(a) Leadership and the teamwork it supported were essential for timely decision-making and the continuation of health care delivery during the pandemic.

The strength of our response has been the camaraderie and goodwill between clinical services. . . .teams have really pulled together wonderfully well. Never had any pushback about COVID and who's taking what responsibility. I think everyone stepped up remarkably. (P10)
Leadership and strong collaboration evident in the CEAG meetings were widely acknowledged and enabled timely solutions and directives to address critical issues.

I think maintaining some of those meetings, where there is a broad input from clinicians to executives in an open format, would be helpful. (P06)
2(b) The pandemic placed urgent and extensive demands on staff, the majority of whom stepped up to the challenges. A recurring theme was unscheduled work hours with demanding workloads. Unsurprising were calls for acknowledgment of outstanding contributions of staff.

I feel like there's a lot of unsung heroes. (P12)
2(c) Information overload from numerous local and international sources, and traditional and social media, often exacerbated staff anxiety and created an onerous task for those responsible for policies and guidelines. Conflicting information, for example about the appropriate type of and circumstances for wearing a mask, was challenging for most. 2(d) Transparency, credibility and accountability of timely directives were noticeably absent.
The initial lack of identified channel(s) of trusted information resulted in misinformation, anxiety and inconsistent practices. Participants voiced concern about operational decisionmaking that sometimes lacked input from staff at the coalface.

One of the things that was potentially lacking was transparency with what was happening at the state level, or within the Ministry of Health level, that appeared to be almost like a black box. (P06)
Missing from state directives was an appreciation that health facilities were not equal pandemic responders and therefore directives needed to be specific and detailed. Timely dissemination of information via the Chief Executive's Broadcasts to all HCWs gave credibility to the rapidly changing workplace requirements. Open forums such as Q&As and Grand Rounds were valued because they allowed staff to seek answers and have further clarity. Some departments also employed additional mechanisms to keep staff informed.
I think the communication was a way of relieving staff anxiety . . .the Chief Executive's daily broadcast was quite helpful . . . Grand Rounds initially was very effective. The Infectious Diseases team was so articulate, and they gave such measured responses, and gave people the information that they needed. (P03) Theme 3: Plan for future crises. The ambiguity surrounding appropriate procedures and directives for the provision of care in a safe environment fuelled feelings of stress and anxiety. Participants described the benefits of a multidisciplinary team armed with the expertise, experience and resources capable of providing an immediate response and ongoing governance and capacity for the wide-ranging components integral to a comprehensive pandemic response.
3(a) COVID-19 demanded an urgent review of usual health care activities. Delays were counterproductive to efforts to keep staff engaged. A taskforce that could be activated at a moment's notice would minimise delays, staff anxiety and the accompanying risks to staff and patient well-being. 3(c) The criteria and a plan for modifications to clinical operations, including escalation and de-escalation of procedures, would enable staff to be prepared and act in unison.
We probably need to have a better consideration of how to stage our transition from a teambased or ward-based system without going from one to the other extreme immediately. (P30) 3(d) Clarity around roles, responsibilities and lines of reporting were blurred or absent during the height of the pandemic, deleterious to patient care and staff well-being. Long hours were spent developing solutions for working at the coalface that were superseded by less fitfor-purpose directives from higher levels of the health sector. A multidisciplinary central control committee could efficiently create expert groups with the authority and responsibility to action urgent and ongoing change.
I think there has been a very strong case for us to have some sort of strong national, multidisciplinary communicable disease centre, where you incorporate all the leaders from these various groups into one entity that could then share their information and make sure that all the information that they're sharing with their groups is consistent. (P10) Theme 4: Promote corporate and clinical agility. Staff and patient safety and well-being are paramount concerns for any health system. Circumstances during the pandemic fashioned unique responses to the provision of health care and staff's ways of working. 4(a) Individual staff/patient characteristics and needs were foremost in the minds of those determining the day-to-day operations in the facility. Staff's age, personal circumstances and physical and mental status were key considerations in determining their vulnerability, and simultaneously, their capacity to contribute to the facility's pandemic response. Similarly, confidence in staff enabled flexibility in caring and advocating for patients. For certain conditions, such as those requiring a physical examination or patient observation, telehealth was deemed unsuitable.
We decided that there were very few visits that we could cut out, or that we could move to video. . . .we needed to keep doing most of these visits as face to face visits, because to do otherwise was going to potentially make things unsafe. (P38)

Discussion
Australia's consistent easing of restrictions from late 2020 signalled the opportune time to capture the lived experiences and perspectives of staff that could inform improvements to quality health care now and into the future. Although the interviewing commenced at a time of no locally acquired COVID-19 cases in the LHD and when the monthly average hospitalisations for the state was 3.4 per day, [30] the comprehensive uncertainty about what was once one's daily routine was the norm. In that environment, we aimed to identify successes to inform facets of health care that should be maintained, and at the same time, document into corporate memory aspects that should be modified if not entirely avoided. Our findings focus on the well-being of HCWs and patients, and aspects of governance and management of a tertiary hospital.

Considerations for ongoing and future provision of health care
Minimise risk of infection. Health care organisations around the world are reassessing how to safely provide essential care for patients in times of crisis [31]. The pandemic elevated the importance of staff safety and prevention of transmission to the community comparable to patient safety [32,33]. Heightened anxiety-stemming from the unknowns of the virus, [3] inconsistent guidelines, and inadequate PPE stocks and directives-was not unique to Australia [34]. Sudden and extensive demands for training stretched the resources of Infection Control and nurse educators. Establishment of a centralised managed stock enabled transparency and ready access, thereby reducing individual hoarding and stockpiling.
The utmost priority given to infection control positively affected WH&S aspects of the healthcare system. Posited as the way forward, infection control practices could be effectively incorporated into routine activities if perceived as a WH&S issue, a concept previously reported [35]. One such example, initiated by the ED, saw staff assigned designated workstations and computers and required to declutter and regularly clean surfaces to reduce contamination and sources of infection. Restricting visits, employed as an early infection control strategy, caused moral injury, [36] particularly for staff unable to apply their professional judgement. Guidelines enabling patients to safely receive visitors [37] reflect an appreciation for the benefits of visitors to patients [38] as well as the need for regulation [39,40].
Efforts directed towards procedural changes and staffing may have relevance to non-pandemic operations [41]. Staff agility enabled the adoption of rapid changes, some temporary as was an innovative process for intubating patients, and others long-term such as avoidance of nebulisers, cohorting patients suffering from infectious diseases and use of suitable physical infrastructure. Work is already underway to review regulations and standards on hospital buildings and the guidelines that govern their operations [42,43]. Minimising the contact between infected and non-infected patients and staff using 'shelter hospitals' [44] would enable non-pandemic operations to continue, thereby minimising the de-escalation of services.
Early designation of a separate testing clinic and ward, the latter equipped with permanent staff and a Nurse Unit Manager (NUM), would support operations, staff and patient safety, and work demands of assigned medical practitioners. Pool staff increased the likelihood of shortcuts of various procedures, unauthorised staff providing directives, PPE breaches, and anxiety and unabated fear among both poorly informed staff and patients.
Maintain a sense of collegiality and informed decision-making. The general motivation of staff to be involved early in the pandemic might have stemmed from feelings of obligation in the presence of facilitators such as the provision of accommodation, and at a local level, transparent information sharing and a sense of inclusion in decision-making, [45,46] which would have alleviated feelings of distress that were common among HCWs [47]. The collaboration participants experienced, desirous across occupational and professional groups, [18] was underpinned by multipronged communication strategies between staff at the coalface and the leadership groups, and was particularly valuable in the periods of rapid change, as noted elsewhere [48]. Recounts of everyone having the same agenda were as common as those of unrostered hours worked-both warranting recognition.
Plan for future crises. Despite SARS-CoV-2 being the third coronavirus to emerge in the past 20 years and experts' previous warnings of impending deadly epi/pandemics [49][50][51], the world was unprepared for COVID-19. In addition to 'a detailed operational blueprint' [51] for an effective response, participants expressed the importance of the retention of a skilled multidisciplinary emergency taskforce and, for sustained analytical and operational capacities, a multidisciplinary central control group. A taskforce would prove invaluable particularly in situations when there is an extended period before the infectious agent is identified such as those presented by COVID-19, compared to the SARS outbreak when researchers quickly identified the infectious agent as SARS-CoV-1.
Up-to-date information, education and training are not only prerequisites for quality patient care but are important for reducing HCWs' risk of psychological distress [52,53], from which full recovery may be challenging [11]. Integrated in the control centre, designated individuals in core response areas such as ICU [40] could establish information channels on the current status of operations that would strengthen collaboration and coordination across diverse but relevant groups. Hand-in-hand with information sharing and having what has been referred to as a transparent strategy [54], is acknowledging uncertainty [55] to abate confusion and panic. Transparency alongside tailored information from trusted spokespeople are similarly relevant to achieving optimal vaccine uptake, which itself is vulnerable to a number of factors including, at any point in time, the public's perception of risk [56,57] and vaccine safety, efficacy and side-effects [58].
An effective control centre would: engage frontline staff and experts across disciplines and levels of governance [59] in decision-making and the development of evidence-based policies and protocols [44], avoiding duplication of processes; prioritise infection control, protection and safety measures ahead of knowledge of disease transmission; [47] create central stocking and stockpiling of equipment to avoid resource strain; [60] and deploy standardised frameworks to keep all staff abreast of updated protocols, guidelines and policies. Acknowledged as a key component of a preparedness plan is a scalable emergency system capable of responding to a surge in demand for resources and patient care [21,61]. Such undertakings of a control centre could fall within the remit of the long anticipated and now imminent Australian Centre for Disease Control [62,63], to address experiences of HCWs that are detrimental to their well-being and mental health [64][65][66][67].
Promoting corporate and clinical agility. Participants extoled the agility of staff as they reflected on efforts to achieve essential elements for a responsive health care environment that provides quality patient care while simultaneously mitigating the spread of the virus amid rapid and frequent change. Similarly, leaders acted swiftly to mitigate risk, introducing a wardbased model of care aimed at minimising the movement and interacting of staff at work, and offering assistance to staff identified as vulnerable-the latter a known effective measure [68]. Risk management included staff taking leave, working remotely and being redeployed. Working remotely, a practice previously considered impractical [69], especially in health care related jobs, became a reality for many in the pandemic [70]. However, still lacking are appropriate guidelines for individual sectors [69] and assessment of its benefits.
Telemedicine proved effective in filling some health care gaps, enabling healthcare services to infected and non-infected people during the pandemic [71]. In our study clinicians had mixed reactions to its sustainability, citing situations when a traditional physical examination is necessary. Nonetheless, most appreciated that remote working has the potential to be costeffective, extend access to specialist care [72], and increase productivity and job performance [73,74].

Limitations
The present study focused on one facility that is a designated COVID-19 facility in Australia, potentially limiting its generalisability. Our purposive sampling however, captured key informants who were representative of crucial sectors of the pandemic response. They were strategically placed to identify successes and gaps in the provision of health care, and to make considered recommendations reflecting both a bird's-eye view and coalface experiences. Despite never reaching the dire situation experienced elsewhere, it can be argued that the four themes hold worldwide applicability-with a number of their sub-components identified as important considerations in studies from Europe [44], Canada [61], and USA [19]-and contain generic concepts with international relevance. Our methods employing Morrow's et al. [28] modification of Colaizzi's phenomenological approach were strictly adhered to and reanalysis was undertaken, culminating in results based on four researchers to minimise researcher bias.

Conclusion
This study presents, to our knowledge, the first report of lived experiences and recommendations from clinical and non-clinical senior healthcare professionals in Australia. Their observations and recommendations should inform decision-makers tasked with mobilising an efficacious approach to the next health crisis and, in the interim, aid the governance of a more robust workforce to effect high quality patient care in a safe environment. Admittedly, the initial challenge rests with leaders who must agree to prioritise fit-for-purpose systems and structures as part of crisis preparedness while simultaneously tackling inexorable current demands. reviewing manuscript drafts, and Leendert Moerkerken who identified and facilitated the transcription process.